Spontaneous Versus Directed Pushing in Labour

Management of the second stage of labour can vary considerably.

Even though research evidence seems to favour spontaneous pushing, directed pushing is still often used. Which method is best?

As every midwife knows, slow and controlled birth of the baby is important to prevent perineal trauma. Lemos et al. (2017) note that there is still no consensus on an ideal strategy for pushing during the second stage, and as Edqvist et al. (2016) point out, there is still very little high-quality research comparing directed versus spontaneous pushing during the active second stage of labour.

Pushing Methods for the Second Stage of Labour

There are two approaches to pushing in the second stage of labour. Historically, directed pushing, also known as the Valsalva manoeuvre, has been favoured. It involves encouraging women to take a deep breath at the beginning of a contraction, hold it and bear down throughout the contraction.

Conversely, spontaneous pushing allows women to follow their own instincts and generally push three to five times per contraction.

Directed Pushing

The Valsalva method of pushing was first introduced in the 1950s and involves the woman taking a deep breath and forcefully pushing throughout a contraction.

However, this can increase the risk of nerve and structural damage to the pelvic floor due to the sudden increase of abdominal pressure and rapid expansion of vagina and perineum (Torkzahrani et al. 2017).

Directed pushing is also associated with the following disadvantages:

• Longer duration of the second stage of labour for both nulliparous and multiparous women;
• Increased risk of a prolonged second stage of labour in multiparous women;
• High rate of episiotomy; and
• Significantly increased risk of neonatal resuscitation or admission to the neonatal unit.

(Lee et al. 2019

There are also adverse maternal outcomes associated with the Valsalva Manoeuvre:

• Increased rate of caesarean sections;
• Increased maternal fatigue; and
• Greater possibility of perineal lacerations and pelvic floor damage.

(Antsaklis et al. 2020)

Neonatal wellbeing can also be compromised by prolonged directed pushing. As Antsaklis et al. (2020) explain, when forceful pushing lasts for more than six seconds, maternal haemodynamic measurements are altered. This results in inhibited venous return to the heart along with decreased cardiac output and lowered blood pressure, which in turn decrease placental blood perfusion. Ultimately this can lead to reduced blood flow and oxygen to the fetus and a higher risk of poor fetal outcomes.

Spontaneous Pushing

A better approach based on current evidence is to delay pushing until the woman feels the urge to push. Not only does spontaneous pushing increase maternal satisfaction, but it also seems to be associated with fewer adverse outcomes (Cooper 2020).

Spontaneous pushing also has the key advantage of reducing tissue damage, as the perineal muscles are allowed to stretch slowly and steadily (Torkzahrani et al. 2017).

There is also the benefit of evoking the Ferguson’s reflex, where oxytocin release is increased, labour is naturally augmented and bearing down efforts become more efficient and less stressful (Antsaklis et al. 2020).

Most researchers seem to agree that having the woman free to follow her own instincts for how and when to push helps prevent perineal tears and therefore reduces the possibility of pelvic floor damage.

This is largely because spontaneous pushing allows for a slower and more controlled descent of the fetus, resulting in a gradual stretching of the perineal muscles. Pushing when an irresistible urge is present also reduces the pressure that is applied on the anterior vaginal wall, the cervical ligaments and the connective tissue supporting the vaginal walls, as pressure is not applied unless the fetus has already started to descend (Antsaklis et al. 2020).

Evaluating the Research

From the point of view of maternal satisfaction, the evidence is overwhelmingly in support of spontaneous pushing, but further well‐designed randomised controlled trials are needed to address other clinically important questions about maternal and neonatal outcomes (Lemos et al. 2017).

For example, Lee et al. (2018) discovered that in nulliparous women there was no difference in the risk of moderate or severe perineal injury between the different techniques, whereas in multiparous women the use of a hands-on, directed approach was associated with a significant increase in the risk of moderate and severe perineal injury compared to the ‘hands-poised’ undirected approach.

Lemos et al. (2017) summarise the current research findings regarding spontaneous versus directed pushing with the following points:

• There was no clear difference in the duration of the second stage (very low-quality evidence).
• Perineal laceration (low-quality evidence).
• Episiotomy, time spent pushing (very low-quality evidence).
• Number of women with a spontaneous vaginal birth (moderate-quality evidence).
• Neonatal outcomes, e.g. five minute Apgar score less than seven (very low-quality evidence).
• Admission to neonatal intensive care (very low-quality evidence).

A further nine randomised controlled trials comparing the methods of directed (Valsalva) and spontaneous pushing on perineal protection were evaluated by de Tayrac and Letouzey (2016).

Two of these trials suggested that spontaneous pushing reduces the risk of perineal tears, but yet again no firm conclusions could be drawn due to the inconsistency of these results. They also noted that Valsalva and spontaneous pushing techniques currently appear comparable in terms of duration, pelvic floor, perineal, and neonatal outcomes (de Tayrac and Letouzey 2016).

In the absence of strong evidence in favour of either technique, they suggest the decision should be guided by a woman’s preference alongside clinical priorities (de Tayrac and Letouzey 2016).

These ambiguous results highlight the need for new, high-quality research to enable midwives to keep their labour and delivery policies updated in line with best practice. Until those high‐quality studies are available, however, Lemos et al. (2017) suggest that women should be encouraged to push and bear down according to their comfort and preference.

As Koyucu and Demirci (2017) also discovered, although the duration of the second stage of labour was often longer with spontaneous pushing, women were able to give birth without requiring any verbal or visual instruction, without exceeding a time limit of two hours and without affecting fetal or neonatal wellbeing.

Conclusion

Current evidence no longer seems to support the practice of directed pushing, as it does not appear to confer any tangible benefits to either mother or infant. It can also have potentially negative effects on the anatomy of the labouring women (Cooper 2020).

Even though there have been many papers discussing which method of pushing is best in the second stage of labour, many midwives are still restricted by labour ward policies of timed second stages, active pushing once fully dilated and subsequent interventions when time runs out.

Perhaps as Cooke (2010) suggests, a change in the definitions used for the stages of labour might give midwives more freedom to let women decide how and when to push.

References

• Antsaklis, P, Papamichail, M, Theodora, M, Syndos, M, Daskalakis, G & Loutradis, D 2020, 'Natural Methods to Assist Delivery during the Second Stage of Labour: Part II: Timing and Type of Pushing', HJOG, vol. 19 no. 1 pp. 11-26, viewed 10 May 2020, http://hjog.org/wp-content/pdf/2020/01_Antsaklis.pdf
• Cooke, A 2010, 'When will we change practice and stop directing pushing in labour?', British Journal of Midwifery, vol. 18 no. 2 pp. 76-81, viewed 11 May 2020, https://www.magonlinelibrary.com/doi/abs/10.12968/bjom.2010.18.2.46403?journalCode=bjom
• Cooper, K 2020, Exploring The Effects Of Second Stage Management From The Maternal And Midwifery Perspectives: Are There Any Benefits To Directing Women? - Insight, Insight Home, viewed 9 May 2020, http://insight.cumbria.ac.uk/id/eprint/2363/
• de Tayrac, R & Letouzey, V 2016, Methods of pushing during vaginal delivery and pelvic floor and perineal outcomes, Current Opinion in Obstetrics and Gynecology, vol. 28 no. 6, pp. 470-476
• Edqvist, M, Hildingsson, I, Mollberg, M, Lundgren, I & Lindgren, H 2016, 'Midwives’ Management during the Second Stage of Labor in Relation to Second-Degree Tears-An Experimental Study', Birth, vol. 44 no. 1 pp. 86-94, viewed 10 May 2020, https://onlinelibrary.wiley.com/doi/full/10.1111/birt.12267
• Koyucu, R & Demirci, N 2017, 'Effects of pushing techniques during the second stage of labor: A randomized controlled trial', Taiwanese Journal of Obstetrics and Gynecology, vol. 56 no. 5 pp. 606-612, viewed 10 May 2020, https://www.sciencedirect.com/science/article/pii/S1028455917302206
• Lee, N, Firmin, M, Gao, Y & Kildea, S 2018, 'Perineal injury associated with hands on/hands poised and directed/undirected pushing: A retrospective cross-sectional study of non-operative vaginal births', International Journal of Nursing Studies, vol. 83 pp. 11-17, viewed 10 May 2020, https://www.sciencedirect.com/science/article/abs/pii/S002074891830083X?via%3Dihub
• Lee, N, Gao, Y, Lotz, L & Kildea, S 2019, 'Maternal and neonatal outcomes from a comparison of spontaneous and directed pushing in second stage', Women and Birth, vol. 32 no. 4 pp. e433-e440, viewed 10 May 2020, https://www.sciencedirect.com/science/article/abs/pii/S1871519218304025
• Lemos, A, Amorim, M, Dornelas de Andrade, A, de Souza, A, Cabral Filho, J & Correia, J 2017, 'Pushing/bearing down methods for the second stage of labour', Cochrane Database of Systematic Reviews, viewed 10 May 2020, https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD009124.pub3/abstract
• Torkzahrani, S, Ahmadi, Z, Roosta, F, Shakeri, N & Mhmoodi, Z 2017, 'Effect of breathing technique of blowing on the extent of damage to the perineum at the moment of delivery: A randomized clinical trial', Iranian Journal of Nursing and Midwifery Research, vol. 22 no. 1 p. 62, viewed 10 May 2020, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5364755/